Marian

 Academy   Mandatory Form  

2015-2016 REGISTRATION APPLICATION  

Please return this completed application to the office along with your registration fee, immunization records, and
Family Commitment Form.  
FOR OFFICE USE
Date Received: ______________
STUDENT INFORMATION
Today’s Applying
If PreK, select:
Date: to Grade: 3 year old 4 year old
st
NOTE: PreK (8:00am – 11:00am Monday - Thursday): must be 3 years old by Sept 1 , 2015 and potty trained
st
Kindergarten (8:00am – 2:45pm Monday – Friday): must be 5 years old by Sept 1 , 2015

Last Name:

First Name: Middle:

Name Used (if different from above):

Address:

City: State: Zip:

Home Phone: Male Female

Date of Birth: Place of Birth:

Age on Sept 1, 2015: Child’s Religion:

Current Grade: Current School:

Previous School (if applicable):

Previous School Address:

Teacher/Counselor Reference:

Currently Enrolled Siblings at Marian Academy: 1.

2.

3.

Previously Enrolled Siblings at Marian Academy: 1.

2.

3.

Student Lives With: Both Parents Mother Father Stepparent Guardian Other

I give my permission for The Marian Academy to use my child’s photograph and/or school work in publications to promote the school.

I give my permission for The Marian Academy to use my child’s photograph on the MA website and/or Facebook page.

Please DO NOT use my child’s photograph and/or school work for The Marian Academy promotion, on the website or Facebook page.

Parent/Guardian Signature: Date:

Marian Academy - Registration Application - July, 2015 1  

STUDENT ENROLLMENT INFORMATION

Today’s Date: Student’s Name:

Please briefly describe the student:

Has the student ever been dismissed from school or repeated a grade?
No Yes
If yes, please explain:

Has the student ever been tested or received special help for a reading or learning difficulty?
No Yes
If yes, please explain:

Has the student ever been diagnosed for or enrolled in a special education program or
special school (ie. resource room LD placement, attention deficit, etc)? No Yes
If yes, please explain:

Are there any additional special needs/considerations we should be aware of?

No Yes
If yes, please explain:

Marian Academy - Registration Application - July, 2015 2  

STUDENT MEDICAL INFORMATION AND RELEASE FORM

Today’s Date: Student’s Name:

Is the student taking any medication regularly?

No Yes
If yes, please list and explain:

Does the student have hearing or vision problems?

No Yes
If yes, please list and explain:

Does the student have a serious allergy to certain foods or insect bites?
No Yes
If yes, please list and explain:

Does the student have a severe reaction to medicine, prescription drugs or antibiotics?
No Yes
If yes, please list and explain:

Health History
Please check the illnesses below that the student has experienced:
Blood Disease Heart Disease Diabetes Hard Measles (Rubeola)
Tonsillitis Ear Infections Mumps Asthma
Pneumonia Chicken Pox Rheumatic Fever Hay Fever
German Measles (Rubella) Kidney Disease Epilepsy Other (please explain)

Has the student had any physical problems, surgeries, disabilities or illnesses not listed above? No Yes
If yes, please list and explain:

What was the date of the student’s last tetanus shot?

Student’s physician’s name and phone number:
Insurance Company: Policy No:
Subscriber’s Name:

Hospitals may be reluctant to treat or care for children without consent from parents or guardians. This can cause delay in treatment if there is a
medical emergency when parents or guardians are not available to give consent. In case of emergency, this form will be taken with the student
to the hospital if medical treatment is needed.

I, ______________________________________, the natural parent/legal guardian of (student) _____________________________________,

authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician or
hospital when in the sole discretion of the attending physician, when treatment and procedures are immediately necessary or advisable in the
interest of my child’s health and well-being, after The Marian Academy has made every effort to contact me.

Under the circumstances set forth above, I elect not to be informed in advance of the nature and character of the proposed treatment, its
anticipated results and possible alternatives, and the risks, complications and anticipated benefits involved in the proposed treatment and the
alternative forms of treatment, including non-treatment.

Signature of FATHER/GUARDIAN Date Signature of MOTHER/GUARDIAN Date

 
Marian Academy - Registration Application - July, 2015 3  
FAMILY INFORMATION

Today’s Date: Student(s) Name:

Are you a registered member of one of the following Parishes?

Our Lady of the Valley (La Grande) How Long?
Sacred Heart (Union) How Long?
St. Anthony’s (North Powder) How Long?
St. Mary’s (Elgin) How Long?
None/Other

Please list the names of children enrolling in The Marian Academy for the 2015 – 2016 school year:
1. Grade:
2. Grade:
3. Grade:
4. Grade:
5. Grade:

Father’s Last Name: First Name:

Address:
City: State: Zip:
Home Phone: Cell: Text? Yes No
Email: Work Phone:
Employer Name: Occupation:
Employer Address: City, State, Zip:

Mother’s Last Name: First Name:

Mother’s Maiden Name:
Address:
City: State: Zip:
Home Phone: Cell: Text? Yes No
Email: Work Phone:
Employer Name: Occupation:
Employer Address: City, State, Zip:

Stepparent Name (if applicable):

Stepparent Name (if applicable):

Marian Academy - Registration Application - July, 2015 4  

DISMISSAL / PICK-UP AUTHORIZATION
Today’s Date: Student(s) Name:

I hereby authorize The Marian Academy to release my child(ren) for dismissal to the following person(s):
Name: Home Phone:
Relationship to Student: Cell/Text:

Name: Home Phone:

Relationship to Student: Cell/Text:

Name: Home Phone:

Relationship to Student: Cell/Text:

Name: Home Phone:

Relationship to Student: Cell/Text:

EMERGENCY CONTACT INFORMATION

Please list two persons to notify in case of an emergency if the parents cannot be reached:
1. Last Name: First Name:
Home Phone: Cell/Text:
Relationship to Student: Work Phone:

2. Last Name: First Name:

Home Phone: Cell/Text:
Relationship to Student: Work Phone:

Parent/Guardian Name (printed):

Parent/Guardian Signature:

Date:
 
 
 
 
 
 
 
 
Marian Academy - Registration Application - July, 2015 5  
The  Marian  Academy Mandatory Form

2015-2016 TUITION FINANCIAL AGREEMENT

Per Year
Registration Fees (NON-REFUNDABLE): Tuition Rates: Per Month
(9 months)
Pre-school: $150 Pre-school: $225 $2025
th th
K-5 Grade: $150 K-5 Grade: $400 $3600
*Tuition is NON-REFUNDABLE if student attends school any portion of the month. See Refund Policy in the Tuition Policy form.

Financial Plan for Tuition (please check one):

Tuition paid in advance and in full (before the start of school) – 5% discount
Quarterly (every three months)
Monthly (every month for 9 months)
Tuition Assistance Application submitted (See Tuition Assistance Policy)

Student(s) Enrolling:
Date Tuition Pymt
st
Name Grade Registration Fee Paid (due 1 of each month)
1. $ $
2. $ $
3. $ $
4. $ $
5. $ $
Total Registration Fee (due at time of enrollment): $ $

Tuition Assistance or Applied Discount $ -

FOR OFFICE USE ONLY
Grand Total Monthly Payments $

Responsible Party:
Last Name: First Name:
Address: City, State, Zip:
Home Phone: Cell/Text:
Email:
Relationship to Student:
I have read, understand and agree to the Tuition Policy terms and agreements.
I have read and signed the Family Commitment Form. I understand that 20 hours of volunteer service is
th
required of all K-8 grade Marian Academy families. Service hours not completed at the end of the school
year will be billed at the rate of $20/hour.
I have read The Marian Academy Uniform Dress Code Guidelines and understand that parent/guardian
compliance to the dress code is necessary for the enrollment of my child(ren).
Print Responsible Party’s Name:

Signature: Date:

Marian Academy - Registration Application - July, 2015 6